ARDS
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Definition
ARDS is a form of pulmonary edema characterized by
severe hypoxemia that can rapidly lead to acute
respiratory failure
Occurs as a result of a direct or indirect lung injury
Although mortality rates have decreased to around 40%,
ARDS is difficult to diagnose and can prove fatal within
48 hours of onset if not promptly diagnosed and treated
Some patients who survive ARDS recover completely,
whereas others experience lasting damage to their lungs
and other health problems
Causes
Examples of a direct lung injury include:
• gastric aspiration
• bacterial, fungal, or viral pneumonia
• pulmonary contusion
• near drowning
• prolonged inhalation of high concentrations of oxygen, smoke,
or toxic substances
Examples of an indirect injury include:
• sepsis • shock (any cause)
• drug overdose • fat embolism
• prolonged hypotension • nonthoracic trauma
• cardiopulmonary bypass • head injury
• acute pancreatitis • uremia
• hematologic disorders, such as disseminated intravascular
coagulation, or multiple blood transfusions
Three Main Phases
In the exudative phase, an injury to the lungs, whether
direct or indirect, leads to an acute inflammatory
response, lasting up to 1 week
In the proliferative phase (sometimes called the
fibroproliferative phase), the inflammatory process in the
lungs occurs systemically throughout all tissues, leading
to increased capillary permeability and movement of fluid
out of the vascular space and into the tissue; this phase
can last up to 1 week
In the fibrotic phase (sometimes called the resolution
or recovery phase), the lungs begin to recover; lung
function may continue to improve over a period of 6 to 12
months
Pathophysiology
Pathophysiology
Is the Stage Set for ARDS?
Signs and Symptoms
The acute phase of ARDS is marked by rapid onset of
severe dyspnea, usually occurring12 to 48 hours after the
initial injury
The patient will experience arterial hypoxemia that
doesn’t respond to supplemental oxygen
Other signs of ARDS include:
• rapid, shallow breathing
• intercostal retractions • pulmonary crackles
• rhonchi • altered mental status
• tachycardia • hypotension
• decreased urine output
• respiratory alkalosis
• cyanosis
Diagnostic Criteria
Occurrence of an acute lung injury or a history of systemic
or pulmonary risk factors
Acute onset of respiratory distress
Diffuse, bilateral infiltrates on chest X-ray
Severe refractory hypoxemia, demonstrated by a P/F ratio
of less than 200 mm Hg
No clinical evidence of left-sided heart failure (left atrial
hypertension), demonstrated by a PCWP of less than 18
mm Hg
Management Strategies
Treatment for ARDS primarily involves supportive care in
the ICU, including:
• providing adequate oxygenation with avoidance of
complications
• drug therapy
• nutritional support
• prone positioning
• permissive hypercapnia
Supportive therapy almost always includes endotracheal
intubation and mechanical ventilation with a low tidal
volume, pressure-limited approach and low to moderately
high PEEP (lung protective strategies)
Lung Protective Strategies
Historically, ventilator therapy for ARDS consisted of
high tidal volumes (10 to 12 mL/kg) with high PEEP (20
to 25 cm H2O) to improve oxygen delivery
High airway pressures commonly caused patients to
develop pneumothorax (barotrauma)
High tidal volumes and PEEP levels significantly
overdistend the alveoli (volutrauma)
The current ventilation strategy is to deliver a low tidal
volume (titrate to 6 mL/kg) and low to moderately high
PEEP (5 to 20 cm H2O) to keep the alveoli open and
diminish the negative effects of high-pressure settings
Drug therapy
A gold standard medication regimen for ARDS has yet to
be developed
Antibiotic therapy is often used in the treatment of sepsis-
related ARDS or to treat confirmed or suspected
underlying infection
A diuretic may be used to increase renal excretion of
water, which decreases pulmonary interstitial and
alveolar edema
A mechanically ventilated patient may need to be sedated
The administration of fluids in patients with ARDS
remains somewhat controversial
Nutritional Support
Nutritional support is critical for the patient with ARDS
Because metabolic demand is high, his caloric needs will
be increased; enteral nutrition is preferred
Adequate calories and protein should be provided,
including polyunsaturated fatty acids such as gamma
linolenic acid
Enteral nutrition formulas have been developed that
provide a large amount of fat calories rather than
carbohydrates
Prone Positioning
Prone positioning is a treatment modality that can be used for
mechanically ventilated patients with ARDS who require high FiO2
levels
It’s recommended that prone positioning be considered early in the
course of treatment
Prone positioning may potentially trigger complications, such as
pressure ulcers, corneal abrasions, and brachial nerve injury
Permissive Hypercapnia
A newer management strategy for ARDS
The allowance of high levels of carbon dioxide in the bloodstream,
achieved by setting low tidal volumes on the ventilator
The patient’s pH is allowed to reach levels as low as 7.2
Has been shown to reduce lung injury and is thought to provide a
protective mechanism against injury from inflammation
Nursing Interventions
Because your patient’s condition could quickly become life-
threatening, frequent assessment of his status, including arterial
blood gas values and hemodynamic parameters, and evaluation of
the effectiveness of treatment are necessary
Encourage frequent coughing if your patient can cough, which will
help loosen excessive airway mucus and maintain open alveoli
If he can’t cough, you can suction the airway if your assessment
determines it’s needed
Nursing Interventions
Frequent turning and repositioning has been found to
improve ventilation and perfusion in the lungs and
enhance secretion drainage
If prone positioning is being used for your patient, closely
monitor his response and for deterioration in
oxygenation: Moving him from the supine position to the
prone position can lead to changes in hemodynamic
stability
Be alert to areas of pressure while your patient is in the
prone position, including the knees, face, and abdomen,
and take care not to overextend his shoulders to reduce
the chance of brachial plexus injury
Nursing Interventions
Monitor your patient for signs and symptoms of cardiovascular
compromise, particularly a decreased cardiac output, which may be
caused by decreased venous return or because of positive pressure
ventilation
Be alert for changes in BP; decreased pulse intensity, oxygen
saturation, or urinary output; and mental status changes
Monitor his lab values, especially the hemoglobin level because an
adequate amount of hemoglobin is needed to carry oxygen to the
tissues
Nursing Interventions
Administer analgesia and sedation as indicated to optimize patient
comfort and reduce anxiety
Follow the CDC’s guidelines for proper hand hygiene to help
prevent infection
To help prevent VAP, implement the Institute for Healthcare
Improvement’ ventilator bundle
The Future of Treatment
Continuous lateral rotational therapy—involves
placing the patient in a bed that turns or repositions him
from one side to the other; it’s recommended that
rotational therapy be performed a least 18 hours/day for
optimal effectiveness
Partial liquid ventilation—involves gradually filling
the lungs with a fluid called perfluorocarbon, which is
believed to help carry oxygen to areas of the lungs that are
filled with fluid and other substances; the patient must be
sedated for this treatment
Corticosteroids—the use of steroids to reduce
inflammation in ARDS remains controversial; however,
recent studies have shown some benefit to low-dose
corticosteroid administration
The Future of Treatment
Inhaled NO gas—NO may be used as a rescue therapy for
refractory hypoxemia in ARDS because it relaxes vascular smooth
muscle, reducing pulmonary hypertension and improving
oxygenation; the benefits generally don’t last more than 24 hours
Surfactant replacement therapy—this therapy has been used
successfully in neonates with respiratory distress syndrome but the
effectiveness in adults remains unclear; the use of aerosolized
surfactant for adults continues to be studied
